Microsurgical Technique for Posterior Inferior Cerebellar Artery-Posterior Inferior Cerebellar Artery In Situ Bypass: 3-Dimensional Operative Video

✓ Cerebral revascularization is often required for the surgical treatment of complex intracranial aneurysms. In certain anatomical locations, vascular anatomy and redundancy make in situ bypass possible. The authors present four patients who underwent revascularization performed using the rarely reported posterior inferior cerebellar artery (PICA)—PICA in situ bypass after their aneurysms had been trapped. At Barrow Neurological Institute, between 1991 and the present, four male patients underwent PICA—PICA bypasses to treat aneurysms involving the vertebral artery, the PICA, or both. The mean age of these patients was 34 years (range 5–49 years). Follow-up studies revealed patent bypasses and no evidence of infarction. Patient outcomes were excellent or good. Multiple surgical techniques have been described for revascularization of at-risk cerebral territories. Often, the blood supply must be derived from extracranial sources through a mobilized pedicle or interposited graft. Certain anatomical locations such as the vertebrobasilar junction, the anterior circle of Willis, and the middle cerebral artery bifurcation are amenable to in situ bypass because there is vessel redundancy or proximity to the contralateral analogous vessel. The advantages of an in situ bypass include one suture line, a short bypass distance, and a close match with the caliber of the recipient graft. Although technically challenging, this technique can be successful and should be considered for appropriate candidates.

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An a3-Anterior Inferior Cerebellar Artery to p3-Posterior Inferior Cerebellar Artery Bypass With Thrombectomy and Trapping of an Anterior Inferior Cerebellar Artery Aneurysm: 3-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa014 ◽

2020 ◽

Vol 19 (3) ◽

pp. E311-E312

Author(s):

Justin R Mascitelli ◽

Sirin Gandhi ◽

Jacob F Baranoski ◽

Michael J Lang ◽

Michael T Lawton

Keyword(s):

Artery Bypass ◽

Posterior Inferior Cerebellar Artery ◽

Cranial Nerves ◽

Artery Aneurysm ◽

Anterior Inferior Cerebellar Artery ◽

Occipital Artery ◽

Cerebellar Artery ◽

Retrograde Filling ◽

In Situ Bypass

Abstract In situ bypasses to the anterior inferior cerebellar artery (AICA) are unusual because, with only one artery in the cerebellopontine angle (CPA), no natural intracranial donors parallel its course. In rare cases, the posterior inferior cerebellar artery (PICA) may have the tortuosity or redundancy to be mobilized to the AICA to serve as a donor. This video demonstrates this p3 PICA-to-a3 AICA in situ side-to-side bypass. A 75-yr-old woman presented with ataxia and hemiparesis from a large thrombotic right AICA aneurysm compressing the brainstem. Strategy consisted of bypass, trapping, and brainstem decompression. Written informed consent for surgery was obtained from the patient. A hockey-stick incision was made to harvest the occipital artery as a backup donor, but its diminutive caliber precluded its use. The bypass was performed through an extended retrosigmoid craniotomy. The aneurysm was trapped completely and thrombectomized to relieve the pontine mass effect. Indocyanine green videoangiography confirmed patency of the bypass, retrograde filling of the AICA to supply pontine perforators, and no residual aneurysmal filling. This unusual in situ bypass is possible when redundancy of the AICA and PICA allow their approximation in the CPA. The anastomosis is performed lateral to the lower cranial nerves in a relatively open and superficial plane. The extended retrosigmoid approach provides adequate exposure for both the bypass and aneurysm trapping. In situ AICA-PICA bypass enables anterograde and retrograde AICA revascularization with side-to-side anastomosis. The occipital artery-to-AICA bypass and the V3 vertebral artery-to-AICA interpositional bypass are alternatives when intracranial anatomy is unfavorable for this in situ bypass.1–6 Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

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Far Lateral Craniotomy for Posterior Inferior Cerebellar Artery–Posterior Inferior Cerebellar Artery Bypass and Trapping of Posterior Inferior Cerebellar Artery Aneurysm: 3-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opy201 ◽

2018 ◽

Vol 16 (4) ◽

pp. E119-E120 ◽

Cited By ~ 2

Author(s):

Sirin Gandhi ◽

Justin Mascitelli ◽

Douglas Hardesty ◽

Michael T Lawton

Keyword(s):

Posterior Inferior Cerebellar Artery ◽

Morphological Characteristics ◽

Occipital Artery ◽

Parent Artery ◽

Pica Pica ◽

Cerebellar Artery ◽

Patient Consent ◽

Far Lateral ◽

In Situ Bypass

Abstract Posterior inferior cerebellar artery (PICA) aneurysms account for 3% to 4% of all intracranial aneurysms with an unusually high predilection towards a nonsaccular morphology making microsurgical clipping or endovascular reconstruction of the parent artery difficult. The management of these complicated aneurysms may require revascularization procedures for flow preservation with aneurysm trapping. Recently, there is an increasing inclination towards intracranial–intracranial (IC-IC) bypasses over traditional extracranial donors. This video demonstrates a side-to-side PICA–PICA in situ bypass with trapping of an unruptured incidental right p1-PICA aneurysm. Radiological lesion progression and presence of dysplastic morphological characteristics prompted surgical management. The aneurysm was not amenable to clip reconstruction due to the dysplastic PICA segment and lack of a discernable neck. Institutional Review Board approval and patient consent were sought. With patient in three-quarter-prone position, a right far lateral craniotomy was performed. A left-to-right p3-p3 PICA bypass was completed. The aneurysm was clipped along with proximal PICA at its takeoff from vertebral artery. Indocyanine green videoangiography revealed complete occlusion of aneurysm and proximal PICA and a patent anastomosis with distal right PICA flow. Postoperatively, patient recovered with no new neurological deficits. Dolichoectatic posterior circulation aneurysms are not readily amenable to clip reconstruction. PICA–PICA in situ bypass is an elegant alternative to existing extracranial–intracranial revascularization constructs (occipital artery to PICA).1 There is lower neurological morbidity associated with IC-IC bypass vs PICA reimplantation due to the deep surgical corridor and its proximity to lower cranial nerves. Additionally, in this patient endovascular occlusion posed a higher risk of thrombotic complications and postprocedural cerebellar edema with brainstem compression.2

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Treatment of an Anterior Inferior Cerebellar Artery Aneurysm With Microsurgical Trapping and In Situ Posterior Inferior Cerebellar Artery to Anterior Inferior Cerebellar Artery Bypass: Case Report

Operative Neurosurgery ◽

10.1093/ons/opx275 ◽

2017 ◽

Vol 15 (4) ◽

pp. 418-424 ◽

Cited By ~ 6

Author(s):

Bryan S Lee ◽

Alex M Witek ◽

Nina Z Moore ◽

Mark D Bain

Keyword(s):

Artery Bypass ◽

Posterior Inferior Cerebellar Artery ◽

Significant Risk ◽

Artery Aneurysm ◽

Lateral Approach ◽

Anterior Inferior Cerebellar Artery ◽

Parent Vessel ◽

Cerebellar Artery ◽

Far Lateral Approach

Abstract BACKGROUND Anterior inferior cerebellar artery (AICA) aneurysms are rare lesions whose treatment can involve microsurgical and/or endovascular techniques. Such treatment can be challenging and may carry a significant risk of neurological morbidity. OBJECTIVE To demonstrate a case involving a complex AICA aneurysm that was treated with a unique microsurgical approach involving trapping the aneurysm and performing in Situ bypass from the posterior inferior cerebellar artery (PICA) to the distal AICA. The nuances of AICA aneurysms and revascularization strategies are discussed. METHODS The aneurysm and the distal segments of AICA and PICA were exposed with a retrosigmoid and far lateral approach. A side-to-side anastomosis was performed between the adjacent caudal loops of PICA and AICA. The AICA aneurysm was then treated by trapping the aneurysm-bearing segment of the parent vessel between 2 clips. RESULTS A postoperative angiogram demonstrated a patent PICA-AICA bypass and complete occlusion of the AICA aneurysm. There were no complications, and the patient made an excellent recovery. CONCLUSION The combination of parent vessel sacrifice and bypass remains an excellent option for certain difficult-to-treat aneurysms. This case involving PICA-AICA bypass to treat an AICA aneurysm serves as an example of the neurosurgeon's ability to develop unique solutions that take advantage of individual anatomy.

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Anastomosis Between the Ascending Pharyngeal Artery and the Posterior Inferior Cerebellar Artery Through the Jugular Foramen

Operative Neurosurgery ◽

10.1227/neu.0000000000001098 ◽

2015 ◽

Vol 12 (2) ◽

pp. 163-167

Author(s):

Khaled Effendi ◽

Elsa Magro ◽

Jean-Christophe Gentric ◽

Tim E Darsaut ◽

Jean Raymond ◽

...

Keyword(s):

Vertebral Artery ◽

Posterior Inferior Cerebellar Artery ◽

Jugular Foramen ◽

Left Vertebral Artery ◽

Cadaveric Specimen ◽

3 Dimensional ◽

Ascending Pharyngeal Artery ◽

Cerebellar Artery ◽

Direct Anastomosis ◽

Posterior Division

Abstract BACKGROUND The ascending pharyngeal artery (APA) may, in very rare cases, supply the posterior inferior cerebellar artery (PICA). In reported cases, when such is the case, the ipsilateral vertebral artery (VA) does not supply the PICA, and most of the time it is hypoplastic. OBJECTIVE To describe a unique cadaveric observation of a direct anastomosis between the posterior division (neuromeningeal) of the jugular branch of the APA and the PICA, where the PICA is also supplied by a normal-size VA. METHODS A direct connection between the APA and the PICA was examined in a cadaveric specimen using a 3-dimensional endoscope and a surgical microscope. RESULTS The enlarged jugular branch of the posterior division of the APA entered intracranially via the jugular foramen in its pars vascularis. It then connected directly with the lateral medullary segment of the PICA. The first segment of the PICA originated from a left vertebral artery of normal size and continued its normal course beyond the junction with the jugular branch of the APA. CONCLUSION Both the VA and the jugular branch of the APA may simultaneously supply the PICA territory. Recognition of this anatomic variant is relevant when planning surgical or endovascular treatments.

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Anterior Inferior Cerebellar Aneurysm Treated by Aneurysm Resection and Intracranial Artery Anastomosis in situ: A Case Report and Literature Review

Frontiers in Surgery ◽

10.3389/fsurg.2021.669433 ◽

2021 ◽

Vol 8 ◽

Author(s):

Chaojue Huang ◽

Shixing Qin ◽

Wei Huang ◽

Yongjia Yu

Keyword(s):

Surgical Treatment ◽

Posterior Inferior Cerebellar Artery ◽

Cranial Nerves ◽

Anterior Inferior Cerebellar Artery ◽

Intracranial Artery ◽

Disturbance Of Consciousness ◽

Cerebellar Artery ◽

Wide Range ◽

Aneurysm Resection

Background: Anterior inferior cerebellar artery (AICA) aneurysms are relatively rare in clinical practice, accounting for <1% of all intracranial arteries. After the diagnosis and location are confirmed by angiography, magnetic resonance, and other imaging examinations, interventional, or surgical treatment is often used, but some complex aneurysms require reconstructive surgery.Case Description: An 8-year-old male child was admitted to the hospital due to sudden disturbance of consciousness for 2 weeks. The head CT showed hematocele in the ventricular system with subarachnoid hemorrhage in the basilar cistern and annular cistern. On admission, he was conscious, answered correctly, had a soft neck, limb muscle strength was normal, and had no cranial nerves or nervous system abnormalities. A preoperative examination showed the right side of the anterior distal arteries class under the circular wide neck aneurysm, the distal anterior inferior cerebellar artery supplying a wide range of blood to the cerebellum, the ipsilateral posterior inferior cerebellar artery absent, and the aneurysm close to the VII, VIII nerves. The aneurysm was successfully treated by aneurysm resection and intracranial artery anastomosis in situ of a2 AICA-a2 AICA.Conclusions: AICA aneurysms are relatively rare; in this case, a complex wide-necked aneurysm was successfully treated by aneurysm resection and anastomosis in situ of a2 AICA-a2 AICA. This case can provide a reference for the surgical treatment of complex anterior cerebellar aneurysms.

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